Place matters: Associations between contextual characteristics and health

Abstract

Background: Large and pervasive disparities are seen across multiple health outcomes, including cancer. Evidence shows suboptimal use of cancer screening among individuals with low socioeconomic status and higher rates of modifiable cancer risk factors (e.g., smoking, obesity, lack of physical activity) among racial and ethnic minorities. A growing number of studies report social and economic contextual effects on cancer outcomes, net of individuals' characteristics. Nonetheless, little is known about the pathways by which place influences cancer screening and health behaviors.^ Aims and Methods: This dissertation comprises an updated systematic review of the association between social and contextual characteristics and cancer screening and three cross-sectional multilevel studies exploring the associations between contextual characteristics and cancer outcomes. The aims of study 1, the updated systematic review, are to: 1) describe the study designs, data sources, population characteristics, operationalization of outcome measures, and contextual measures and 2) describe the associations between contextual measures and cancer screening utilization. Studies 2 and 3 linked individual-level data on colorectal cancer screening (CRCS) and breast and cervical cancer screening, respectively, from the 2010 Health of Houston Survey with a comprehensive set of tract level socioeconomic measures from the U.S. Census and the U.S. Department of Housing and Urban Development. Two-level random intercept models were used to test whether contextual characteristics were associated with adherence to several cancers screening modalities. Finally, study 4 tested the association between a small-area measure of residential segregation and prevalence of smoking, obesity, and insufficient physical activity among Hispanic adults.^ Results: The updated systematic review identified 10 eligible studies without consistent patterns in the association between contextual characteristics and cancer screening. Studies 2 and 3 demonstrated that while the majority of tested associations were not statistically significant, those that were differed by screening modality. We found that individuals who lived in areas of high unemployment were less likely to report adherence to CRCS while women who lived in areas of high poverty, crowding, and Hispanic composition were less likely to report up-to-date mammography screening. No association was observed for Pap smear. In study 4, residential segregation was positively associated with obesity among Hispanics; no associations were found for smoking and lack of physical activity, however. Conclusion: Neighborhood socioeconomic disadvantage is increasingly recognized as a determinant of health, and our findings suggest that the effect of place characteristics may extend to cancer outcomes and health behaviors. A better understanding of the multilevel pathways by which place influences health may help point to effective interventions and policies for reducing cancer outcome disparities.^